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Since the 1930s, we’ve enjoyed around eight decades of easily cured gonorrhea — at least in places with easy access to antibiotics — but experts fear those days are numbered. In the past year or so, cases of untreatable gonorrhea have occasionally made headlines.

Thanks to the powers of evolution, some bacteria have acquired the multiple genes necessary to withstand the onslaught of the pills and shots administered by doctors. Gonococci, the bacteria that cause gonorrhea, are starting to win this “arms race” with humans, whose antibiotic arsenals are losing effectiveness. And with gonorrhea on the rise, gonococci may be evolving at an ever-quickening clip.

In 1879, Listerine claimed to cure gonorrhea. Today, scientists are finally testing that claim. We await the results.

Oral Gonorrhea: The Silent Scourge

Many experts believe oral gonorrhea is a key driver of antibiotic resistance. These infections usually don’t cause symptoms, and without symptoms people usually don’t seek treatment. Without treatment, gonococci can hang out in a throat for up to three months.

After transmission by oral sex — and possibly even by kissing — gonococci can set up camp in the throat, which is an ideal environment for acquiring antibiotic resistance. They might not be causing symptoms, but they’re not sitting there twiddling their thumbs, either. If there’s one thing gonococci love to do, it’s collecting genes like some of us collect trading cards, and the throat is a gathering place for closely related bacteria species that hand out antibiotic-resistance genes for their expanding collections.

In late March, the BBC reported a story that was widely repeated in headlines across the world: “Man has ‘world’s worst’ super-gonorrhoea.”

The article told the story of a British man whose symptoms started in early 2018, about a month after he had picked up the bug during a visit to Southeast Asia. Once back home, his doctors were unable to cure it with the standard combination of azithromycin and ceftriaxone — “the first time the infection cannot be cured with first choice antibiotics,” the author wrote.

In most of the world, we don’t have a good picture of antibiotic resistance in gonorrhea.

Actually, a similar case of multidrug-resistant gonorrhea had been documented in the United Kingdom in late 2014, as noted in the New England Journal of Medicine. It was the first verified case to fail to be cured by the azithromycin/ceftriaxone combo — the infection didn’t go away until after the patient was given a double dose of both antibiotics, but by then it had been 112 days and the infection could have cleared on its own. By July 2017, the World Health Organization (WHO) had noted that there had been multiple documented cases of gonorrhea that were “untreatable by all known antibiotics.”

What was different about the man in the BBC story was that his case of ceftriaxone-resistant gonorrhea had a higher level of azithromycin resistance than those that came before. While it may not have truly been the first case of multidrug-resistant gonorrhea that couldn’t be treated with the standard dual therapy of azithromycin and ceftriaxone, it was the “most serious.” Continue reading →

Health authorities have been worried about it for a long time now, and we’ve been following it on our blog since 2012. The boogeyman? Antibiotic-resistant gonorrhea, a strain of the sexually transmitted bacteria that is becoming more and more difficult to treat. Higher doses of the drug will be needed to cure stubborn cases of gonorrhea — until the doses can no longer be increased. Then, untreatable gonorrhea could be a reality.

“Little now stands between us and untreatable gonorrhea.”

The World Health Organization (WHO), in a press release last month, finally used the word “impossible” when describing treatment of antibiotic-resistant gonorrhea, referring to documented cases of gonorrhea that were “untreatable by all known antibiotics.” Worse, these cases are thought to be the proverbial “tip of the iceberg,” as there aren’t good data on antibiotic-resistant gonorrhea in many developing countries, where gonorrhea is more prevalent and epidemics could be spreading under the radar. Adding to this problem is the fact that gonorrhea rates are climbing worldwide, which is thought to be due to a number of factors, including the decline in condom use, the frequent absence of symptoms, inadequate treatment, and increasing urbanization and travel.

What will happen if gonorrhea can’t be cured? Your infection could clear up on its own, after a lengthy battle with your immune system, but we don’t know a lot about how long this could take (weeks? months? never?). Unfortunately, despite your immune system’s best efforts, gonorrhea doesn’t go out without a fight. Gonorrhea can lead to pelvic inflammatory disease, which can cause tissue damage to the reproductive organs resulting in infertility, ectopic pregnancy, and chronic pain. It can also cause scarring that blocks sperm’s movement out of the testes, resulting in epididymitis, which is associated with infertility, chronic scrotal pain, and testicular shrinkage. Furthermore, gonorrhea increases risk for HIV transmission and can be passed to a baby during childbirth. The CDC estimates that, in the United States alone, untreatable gonorrhea could cause 75,000 cases of pelvic inflammatory disease, 15,000 cases of epididymitis, and 222 extra HIV infections over a 10-year period. Worldwide, where gonorrhea and HIV disproportionately affect developing countries, these problems could get even more out of control. Continue reading →

A few years ago, the Centers for Disease Control and Prevention (CDC) put out a “greatest hits” list of antibiotic-resistant pathogens. More recently, in late February, the World Health Organization (WHO) followed suit with a dirty-dozen list of 12 “superbugs,” which was composed mostly of potentially fatal microbes that are becoming increasingly impervious to the drugs that once easily killed them. These are the bacteria WHO believes represent the greatest microbial threat to human health, and the list was compiled in the hopes of providing direction — and motivation — to pharmaceutical researchers who are desperately needed to develop new antibiotics.

Investing in antibiotic development now will save lives later.

A quick primer on antibiotic resistance: Antibiotics kill living organisms called bacteria, but like all living organisms, bacteria can evolve. Just as giraffes evolve longer and longer necks that allow them to eat more and more leaves, so too do bacteria evolve resistance to antibiotics. For example, a resistant bacterium can evolve the ability to spit out the drug before it has a chance to kill it, or it can evolve structural changes to its cell wall that make it impossible for the drug to attach to it.

One superbug, classified as an “urgent threat” by the CDC and a “high priority” by WHO, stands out from the pack. Unlike the other bacteria in these lists, an untreated infection with this bug isn’t thought to be deadly — but it still wreaks enough havoc to merit special attention from such esteemed bodies as the CDC and WHO. That bug is Neisseria gonorrhoeae, and you have one guess what disease it causes. (If you said gonorrhea, you guessed right.) Continue reading →

We’ve been anticipating its arrival for years now, but earlier this fall, the Centers for Disease Control and Prevention (CDC) finally made an announcement: Cases of gonorrhea resistant to the last drugs we use to cure it are emerging.

Over the years, gonorrhea has evolved resistance to every drug we’ve thrown at it — sulfonamides, penicillins, tetracyclines, macrolides, fluoroquinolones, and narrow-spectrum cephalosporins. The last line of defense we have is a one-two punch of a pair of antibiotics: azithromycin and ceftriaxone. By using two drugs, we can delay the inevitable evolution of antibiotic resistance by attacking the bacteria in two vulnerable locations, rather than just one, making it more difficult for the bug to mount a defense and pass on its superior survival skills to subsequent generations.

Prevention is paramount: Stop the spread of antibiotic resistance by practicing safer sex!

Unfortunately, we could only stave off the inevitable for so long. At their conference in September, the CDC announced a cluster of gonorrhea infections that are highly resistant to azithromycin, and that fall prey only to high doses of ceftriaxone. As gonorrhea’s tolerance to ceftriaxone increases, the infection will get more and more difficult to cure.

This cluster of drug-resistant cases was identified in Honolulu in April and May of this year, with five infections showing “dramatic” resistance to azithromycin, as well as reduced vulnerability to ceftriaxone. The good news is that these cases were cured with higher-than-usual doses of antibiotics, but the bad news is that dosages can only climb so high before a drug is no longer considered to be an effective treatment. Continue reading →

Ever since the advent of effective antibacterial therapies less than a century ago, humans with access to these drugs can easily cure gonorrhea. Most of us in the developed world have forgotten that this disease was once a leading cause of infertility in women and blindness in babies — sulfa drugs and antibiotics not only erased these infections from our bodies, they also erased memories of gonorrhea’s dangers from our collective consciousness.

There are two drugs remaining to treat gonorrhea, and resistance to them is climbing higher as the years march on.

Unfortunately, thanks to their talent for genetic gymnastics, gonococci, the bacteria that cause gonorrhea, have been evolving resistance to every drug we’ve thrown at them — to tetracycline, to penicillin, and more recently to fluoroquinolones. One class of antibiotics remains to treat gonorrhea: cephalosporins. In 2013, Centers for Disease Control and Prevention (CDC) Director Tom Frieden warned that we could find ourselves in a “post-antibiotic era” – unless we take precautions. And, just two weeks ago, the latest study from the CDC’s Gonococcal Isolate Surveillance Project sounded the alarm that the post-antibiotic era is drawing ever closer, especially when it comes to gonorrhea.

Azithromycin and ceftriaxone, the two drugs that are used in combination to deliver a one-two punch to invading gonococci, are the best antibiotics remaining in our arsenal. Azithromycin is taken by mouth, while ceftriaxone is administered by a shot, and when taken together they team up to target different weak points in gonococci’s armor. Azithromycin interferes with the bacteria’s ability to make proteins, shutting the cells down, while ceftriaxone causes the cell wall to fall apart. However, the gonococci can acquire resistance. For example, in the case of azithromycin, a resistant bacterium can spit out the drug before it has a chance to kill it, or it can change the shape of its protein-making apparatus such that the drug can’t attach to it. Continue reading →

You’ve probably heard of MRSA, which is pronounced “mersa” and stands for methicillin-resistant Staphylococcus aureus — a strain of bacteria that is resistant to methicillin, as well as pretty much every other antibiotic out there. MRSA is an example of evolution by natural selection — what didn’t kill its ancestors made them stronger, spawning a drug-resistant strain.

There are drug-resistant strains of gonorrhea, trichomoniasis, and syphilis.

Evolution is the force behind life’s diversity. Normally, diversity is a good thing — but when it comes to microbes that cause diseases like gonorrhea, trichomoniasis, and syphilis, these organisms’ ability to evolve new defenses against our antimicrobial drugs isn’t good for us.

STDs have plagued us for millennia, but it wasn’t until the 20th century that we finally developed antibiotics, which gave us a powerful tool against many of our most formidable sexually transmitted foes. Suddenly, scourges like gonorrhea and syphilis could be quickly and easily treated with a dose of penicillin.